Provider Demographics
NPI:1588294250
Name:KENNEDY, WYATT TRISTON
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:TRISTON
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 ROWLETT RD STE 145
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75089-7927
Mailing Address - Country:US
Mailing Address - Phone:972-343-8002
Mailing Address - Fax:
Practice Address - Street 1:5700 ROWLETT RD STE 145
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75089-7927
Practice Address - Country:US
Practice Address - Phone:972-343-8002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician